Provider Demographics
NPI:1962875245
Name:WAGONER, AUTUMN (LISW)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5982 RHODES RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-8100
Mailing Address - Country:US
Mailing Address - Phone:330-673-1347
Mailing Address - Fax:330-678-3677
Practice Address - Street 1:535 E. MARKET STREET
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304
Practice Address - Country:US
Practice Address - Phone:330-379-0667
Practice Address - Fax:330-678-3677
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.15003011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI.1500301OtherLICENSE